Holland looks to future of euthanasia

By Ellen Goodman

AMSTERDAM - It began with the oddest of rallying cries. People started talking about the "right to die" as if dying were not an inevitable human condition.

By the 1970s we had seen more than our share of people tied, tubed and plugged in to a semblance of life. Gradually some began to wave the banner of patients' rights and reclaim power from medical technology and technocrats playing doctor.

But somewhere along the way the right-to-die movement went from asking about stopping treatment to asking for a doctor's help in dying. Now this is at the heart of the assisted suicide case before the U.S. Supreme Court.

Anyone looking for hints about the direction of this debate will find them here in Holland, a country that has struggled to both allow and control doctor-assisted dying.

What began here too as a patients' rights movement has in some ways ceded both more power and greater burdens to doctors.

What began here too as an attempt to resolve the conflict that can arise between a doctor's obligations to both prolong life and relieve suffering has ended up with more conflicts left at the doctor's hand.

In Holland, euthanasia, defined as the termination of life by a doctor at the express wish of a patient, remains technically illegal. But it's permitted under state guidelines in cases of "unbearable suffering." Here nearly 80 percent of doctors have been asked for euthanasia but nine out of 10 requests are turned away. And while the overwhelming majority of Dutch doctors believe it is justified in some cases, only 32 percent have actually assisted in deaths.

One of those is Herbert Cohen, an articulate family physician from Rotterdam. Retired now, he teaches others who confront this issue routinely. I ask him what question troubles doctors the most and he says, without hesitation, "Is the patient suffering enough?"

The long government form doctors are required to fill out after assisting any death asks whether "the suffering was of such a nature that he or she could experience it as intolerable." Simple enough, but as Dr. Cohen acknowledges, "There are no objective criteria for making such a judgment."

Indeed this thoughtful, bearded elder admits his own decisions were based on some reckoning of "How would I feel in such a situation."

Even though these judgments are made in consultation with another doctor, opponents of euthanasia are uncomfortable giving them the power of life and death. At Catholic University in Nijmegen, Henk Ten Have wondered aloud, "What is surprising to me is that people put so much trust in the medical profession."

This month in the United States, a Congress that has yet to provide health care to all children pre-emptively banned federal payment for "assisted suicide." But in Holland where everyone is covered and most have a longtime family doctor, there is no evidence doctors fulfill death wishes cavalierly.

Decisions weigh - and heavily - on Dr. Cohen's colleagues. He describes the difficult passage that begins when a patient raises the subject or when he as a doctor says, "If you ever want to talk about euthanasia I won't blush." It is, he says, "like climbing a terrible mountain."

The burden on doctors may be even greater in countries like our own where the issue is still shrouded in secrecy. Where doctors asked for help in dying cannot even talk to each other.

On my final day in Holland, Eugene Sutorius, the chief lawyer who helped push his country to the frontier of doctor-assisted death, sits at an antique table in his sleek Arnhem office and looks back over the cases of patients' rights and doctors' conflicts that have marked his career.

I ask him where it all leads, and the intense, engaged man answers my questions with his own. "Will we look back and say, at the end of the 20th century we had that euthanasia thing - but now our doctors have learned to put their weapons down and we die in peace?

"Or are we going through a cultural change to a new situation in which death will become a personal option?"

What we do know is that the long and public euthanasia debate has taken another turn. Dutch doctors are talking more fervently today about reducing suffering through palliative care. Time and again, crossing this small county, I was told the same thing: "Euthanasia should remain a possibility but a last resort."

Indeed that may be the best balance. And the most difficult to maintain.

The Boston Globe Newspaper Company